Where’s the Wisdom In Psychiatry?

This the unaltered script for a grand rounds presentation I gave to my fellow psychiatric staff, and other attendees, at my workplace—MaineGeneral Medical Center in Augusta, Maine—on February 24, 2022. I’m posting it verbatim in the spirit of full disclosure—how I present these issues to my colleagues—so that there will be no question regarding the integrity and the consistency of my message.

I'd like to start by asking you all a few questions. How many of you are aware of the CDC Suicide Study released in June 2018? Can anyone tell me how many years of suicide cases were examined in that Study? How did the rate of suicide change in those years? What demographic group showed the largest change in the rate of suicide?

I’ll be asking all of you to step back from your day-to-day practice of psychiatry, and take a hard look at our shared profession. My observations and opinions may provoke some defensiveness–because I’m asking all of us here to reexamine the assumptions of our shared treatment model, and the choices that we’re making every day. I believe that self-examination is demanded of everyone who belongs to a profession. And if changes need to be made to our model of care, it would be best if they arose from within our profession.

Where is the wisdom in our current treatment model of psychiatry? Before we address that question, we should agree on a definition of “wisdom." Googling the definition yields a surprisingly broad array of results–more than I’ve ever seen for any single word. I think it might just be the  most ambiguous word in our common language–one of those “I know it when I see it” kind of things. It can generally be described as the power of discerning and judging properly what is right, typically gained by having many experiences in life. Or it can be the natural ability to understand things that most people can’t. 

My favorite of the definitions I found was posted online from the 1828 edition of Webster’s Dictionary: “The right use or exercise of knowledge; the choice of laudable ends, and of the best means to accomplish them." This definition alludes to the Greek concept of “phronesis”, described as: “The ability to figure out what to do, while at the same time knowing what is worth doing.”

Wisdom is generally regarded to be a mature sort of knowledge that is most commonly gained from experience–especially if that experience happens to be painful.  The Chinese philosopher Confucius observes: "Do you not see how necessary a world of pains and troubles is to school an intelligence and make it a soul?"

Or as the 20th century humorist Will Rogers states: "Good judgment comes from experience, and a lot of that comes from bad judgment." 

My own life verifies that principle. Nowadays my lovely wife Aimee reminds me when I'm being foolish or self-absorbed--and some of my colleagues may notice as well. But I can assure you I'm not nearly as self-absorbed, foolish, or judgmental as I was in my younger days. Two failed marriages, and one disastrous firing from a job I held for over a decade made me keenly aware of my deficiencies--even if I haven't been able to totally quash them yet. 

My principal source of wisdom has been Buddhism, which I've conveniently distilled down to the Second Noble Truth: "Desire is the cause of all suffering." I've found that life is indeed more enjoyable if I resist the urge to expect favored outcomes, and instead remind myself that the world is likely to let me down. But my first exposure to wisdom was through my father, Stephen Minot, who frequently told me: "Son, some people have experience. Others just have experiences." Every day of my psychiatric practice validates that observation. 

There are other ways to gain wisdom, but experience is the most effective--because it is often motivated by desperation, and because pain is so instructive. As Confucius states:

"By three methods we may learn wisdom: First, by reflection, which is noblest; second, by imitation, which is easiest; and third by experience, which is the bitterest." 

Wisdom is the means by which people accommodate themselves to the pain and pitfalls of the world, and its persistent failure to meet our expectations. The first step in doing so is to attain humility. As the Persian philosopher Rumi states:

“Yesterday I was clever, so I wanted to change the world. Today I am wise, so I am changing myself.”

This prerequisite of humility is a common thread. The history of Western philosophy begins with Socrates–who asserts that the first step in acquiring wisdom is to be aware of our ignorance, stating that:

“The only true wisdom is in knowing you know nothing….True wisdom comes to each of us when we realize how little we understand about life, ourselves, and the world around us.” Socrates asks us not only to accept our ignorance, but to honor it–noting that, “Wonder is the beginning of wisdom.”

It’s my hope to see psychiatry develop and mature into a more holistic field–one that can incorporate the ability to dispense wisdom into its treatment model. Patients are often hospitalized while in the midst of a crisis resulting from overwhelming psychosocial stresses–the same kind of painful experiences that have the capacity to become teaching moments, opening our minds to the acquisition of wisdom. It’s my observation that these patients are very likely to be prescribed one or more medications before they’re discharged, but they are less likely to gain any practical wisdom from their experience–no examination of the psychological issues that created their situation, or full consideration of the responses available to the patient. 

Instead, patients are told that they have one or more psychiatric diagnoses, each based on a catalog of intentionally superficial observations–that exist largely to direct and justify our medication interventions. Little if any effort is given to promoting emotional growth, except in rehabilitation groups–where pursuit of personal goals are limited by the group environment, confidentiality concerns, time constraints, and the heterogeneity of the patient population.

Exploration of personal issues on an individual basis may be limited by a number of factors, including:

 –Time constraints on treatment providers

–The risks of increased patient agitation and/or disruption of patient engagement

–Negative ratings on patient satisfaction surveys

–Lack of training in the appropriate skill set

–Incompatibility with our prevailing treatment model

The last of these is certainly the most troubling. The treatment model of modern psychiatry has no place for wisdom or emotional growth–because it perceives emotional dysregulation as pathological, rather than a natural response to distress. It’s also based on a reductionist view of the brain that negates not only the mind, but also the profound impact of life experience. 

It’s worth noting that the word “crisis” was originally the Greek word for “decision.” Many hospitalizations are driven by circumstances forcing the patient to make difficult choices, none of which are particularly desirable. Confronting these issues can be quite provocative, and many patients will be resistant to doing so. That resistance may thaw after a period of reflection–but as we all know, many of our patients are not yet in the habit of reflecting.

But before we even consider taking on the job of dispensing wisdom, psychiatry needs to put its own house in order–and confront the dubious reasoning that underlies our current model of care.  As we all know, psychiatry prides itself on its alleged adherence to science–which is defined as the study of nature. Psychiatry is defined as the treatment of disorders of thought, emotion, and behavior. But just how far have we come in understanding the physiology of thought, emotion, or behavior?

The answer, as we all should know, is close to nowhere. We have no definitive knowledge as to how memories are stored, how thoughts are generated, or how emotions are produced. The reigning model we most often refer to is synaptic plasticity–which was first proposed in 1949. It has some evidence of being an actual physiological process, but by no means has it been confirmed as the definitive answer to any of the above questions. 

Let’s start at the root of all scientific knowledge–the scientific method. The scientific method was invented about a thousand years ago by Hasan Ibn al-Haytham–an Arabian scientist who studied mathematics and physics, and is credited with inventing the field of optics. It's been described by physicist Jose Wudka as "the best way yet discovered for winnowing the truth from lies and delusion." I’m sure we all learned the steps of the scientific method in school–but it’s my opinion that psychiatry could use a refresher course, so bear with me.

The steps of the scientific method are as follows:

1. Make an observation of a phenomenon.

2. Frame a question as to why or how this phenomenon is occurring.

3. Formulate a hypothesis--a testable explanation--to answer that question.

4. Use the hypothesis to predict outcomes. Formulate deductions (for example, “If this is so, then this should happen”) that can be evaluated in experimentation. 

5. Test the hypothesis through experimentation and further observation, and modify the hypothesis in light of the results.

6. Repeat steps 4 and 5 to refine the hypothesis, until there are no discrepancies between your hypothesis and the results.

If your experimentation has produced a hypothesis that’s demonstrated its predictive value, you and other scientists should willfully try to disprove it. A valid hypothesis should stand up to such testing. 

Ibn al-Haytham demands that we not be tempted to short-circuit this process of confirmation for any reason, including money or other worldly gain. As he states:

"Truth is sought for its own sake. And those who are engaged upon the quest for anything for its own sake are not interested in other things."

These “other things” that we’re not supposed to be interested in include the justification of our status as physicians, the funding of pharmacological research, the marketing of pharmaceutical products, and billing for hospital services. The vast majority of psychiatric research is not spent in pursuit of scientific knowledge–a greater understanding of our nature, such as brain physiology. Instead it is spent on technology –the application of existing scientific knowledge for practical purposes, like the development of new medications. In psychiatric research, the ratio of financial interest vs. hard scientific knowledge is overwhelming.

Ibn al Haytham also calls for the persistent application of skepticism to all hypotheses until they are overwhelmingly confirmed to be true, stating:

"The duty of the man who investigates the writings of scientists, if learning the truth is his goal, is to make himself an enemy of all that he reads, and to attack it from every side. He should also suspect himself as he performs his critical examination of it, so that he may avoid falling into either prejudice or leniency."

As we can see, the scientific method and wisdom both insist that the highest priority of all is to know what we do not know. 

We may not notice or acknowledge it, but we are in the business of fixing people’s lives. In order to properly do this job, we should have a profound understanding of just how complicated any person’s life is. Consider your own life–all the events and relationships that contributed to your growth, caused you pleasure or pain from your youth, and your adulthood; all the experiences that have made you the person you are, some of which are not even fresh in our memory. It would take another lifetime to recount your lifetime–and it would still be incomplete.

The same is true of any patient that we are treating. If we were to exercise wisdom in our practice of psychiatry, it would start with acknowledgement of this fundamental ignorance, and embracing the humility that should accompany it. Even in the face of hostile or manipulative behavior, in my practice and in my own life, I try to summon up some sympathy for the other–by taking stock of all the life events that could have made that person who they are. It doesn’t necessarily make me like them, but it does help me to maintain a therapeutic attitude.

The current model of psychiatric care doesn’t allow for such subtleties. We’re not expected to take stock of people’s lives or complexities–all of that is reduced to diagnoses that are simplistic by design and devoid of nuance, driven by checklists rather than understanding. Let’s acknowledge the truth of modern psychiatric diagnosis. It's an idiot-resistant model that is obviously designed not to promote the understanding of patients, but to facilitate the prescription of medications. It also has administrative advantages, greatly simplifying the process of defining standards of psychiatric care.

If anyone is feeling hurt or offended by these observations, please note that this is not directed at anyone in this room. All of us, myself included, are required to work within the system as it exists–in order to do the job that we enjoy, and provide care to the patients that we serve. As long as we look like we're prescribing the right medications, then on paper we're doing our jobs. But the practice of medicine ultimately answers to a higher moral authority than the Joint Commission, an insurance company, or a state medical licensing board.

The phrase “Primum non nocere”--”First, do no harm”--is commonly attributed to Hippocrates as part of his physician’s oath, but is actually a Latin paraphrase of his ideals. It's commonly interpreted in modern days as “If you cannot do good, then at least do no harm." Touted as the guiding principle in modern medicine, it calls for discretion in initiating medical treatment, with due consideration of potential risks–with the same presumption of ignorance and humility that guide both wisdom and the scientific method. 

When I was a psychiatric resident, the prescription of antidepressants was limited only to severely depressed patients, due to the side effects and potential lethality of the only antidepressant agents that were available then–tricyclic antidepressants, and MAO inhibitors. Tricyclics were much more commonly used despite their lethality–because of the dietary and medication restrictions that MAOIs required.

In my early years of community mental health practice I encountered a phenomenon that I dubbed “the tricyclic cycle”:  The patient is prescribed a tricyclic antidepressant, quits it because of dry mouth or other side effects, becomes depressed, overdoses on the bottle of leftover medication in their medicine cabinet, and is admitted to the ICU–where I then see them in consultation for readmission to the psychiatric unit, where they were restarted on a tricyclic antidepressant.

In January 1988, the introduction of a literally generational drug –Prozac– ushered in the modern era of antidepressant medication. A good friend of mine from medical school and residency was in private practice in Austin. Because his patients had private insurance, he had access to Prozac before I did, and after a few months he prophetically told me: “Paul, it’s the first antidepressant that I would take!” Its popularity soon exploded with the publication of a bestselling book, Dr. Peter Kramer’s Listening to Prozac, which introduced the concept of “cosmetic psychopharmacology”--the use of psychoactive substances to treat conditions that were at the time regarded to be either normal, or subclinical variants.  Psychiatry hasn’t been the same since. 

The concept of “cosmetic psychopharmacology” expanded with the introduction of anticonvulsant agents. These were safer medications to prescribe than lithium–and more broad-ranged in their efficacy, since anticonvulsants by definition have the generalized capacity to suppress neuronal hyperexcitability. This led to a broader definition of what constituted “treatable” mood instability. Soon afterward came the arrival of “atypical” or “second generation” antipsychotics, which greatly improved the tolerability of medications used to treat psychosis. These new medications were so well tolerated that they were eventually used to treat diagnoses never dreamed of with their predecessors. 

The result has been the virtual elimination of psychotherapy as a primary treatment for any degree of depression, anxiety, or mood instability. In my training we were taught that our feelings were trying to tell us something that we needed to understand and address. In my lifetime I’ve been through at least two episodes of major depression, one of them accompanied by severe obsessive-compulsive symptoms. Both of them were precipitated by my own foolish choices in life–and both of them eventually resolved without medication. I’ve come to recognize that choices have consequences–some of them experienced as physiological. Fortunately I was a psychiatrist with psychoanalytic training, and I  frankly grew from the experience thereof.

This expansion of modern antidepressants and other psychoactive medications into the marketplace has occurred on the assumption that these medications are relatively harmless. I am greatly appreciative of their non-lethality. Thanks to Prozac and its progeny, I no longer have to feel like I’m writing a monthly prescription for a loaded gun. There’s no arguing with the fact that these modern medications are safer, more tolerable, and thus more effective than the old ones were.

But wisdom demands that we look at the larger picture–and that picture isn’t pretty.

In 2013, an estimated 40 million Americans—16.7% of the adult population—filled one or more prescriptions for psychiatric medications.¹ 12% of adults were on antidepressants, 8.3% on anxiolytic or sedative medications, and 1.6 % on antipsychotic agents. 

In 2018, 15.5 million Americans had been taking antidepressant medications continuously for at least five years.² This rate had almost doubled since 2010, and more than tripled since 2000. Nearly 25 million adults have been on antidepressants for at least two years, a 60 percent increase since 2010. With such a vast increase of people in psychiatric treatment, it would be logical to assume there would be evidence of significantly improved psychiatric health….right? 

June 2018 saw the release of a landmark study by the Center for Disease Control examining all the suicides that occurred in the United States from 1999 to 2016. Their most significant finding was the fact that over this 17-year span, suicide rates in the United States rose by 30%--from 10.4 per 100,000 people in the year 2000, to 13.5 per 100,000 in 2016. The rate increased on average approximately 1% per year from 1999 to 2006 and by 2% per year from 2006 through 2016. 

Men have historically been more prone to suicide than women, and in 2016 the suicide rate for males was 3.7 times the rate for females. However, from 1999 to 2016 the suicide rate among men increased by 21%--while the suicide rate among women increased by nearly 50%. There was a shocking 70% increase in suicide for girls age 10-19, especially those age 10-14. 

Followup statistics from 2017 and 2018 revealed that the rate of suicide continued to grow by about 2% a year–confirming a 35% increase in the suicide rate from 1999 to 2018, from 10.5 to 14.2 deaths per 100,000.³ Almost twice as many children were hospitalized in 2015 for suicidal thought or behavior than there were in 2008.  Suicide has become the second leading cause of death among those age 10 to 34, and the fourth leading cause of death for those age 35 to 54.

Prozac was introduced to the market in 1988–and over the next 20 years, the proportion of Americans on disability for psychiatric illness more than doubled. From 1996 to 2007, the proportion of children on disability benefits more than doubled. In contrast, the proportion of Americans on disability for non-psychiatric diagnoses decreased over the same time period. 

If we have better treatments for psychiatric illness, then why are we having increased mortality and increased disability? I believe part of the answer is expressed in a riddle:

How does psychiatry radically differ from all other medical specialties? 

If you diagnose someone with liver disease, it has absolutely no effect on their hepatic function.

Diagnosing someone with a psychiatric disorder is not as benign as we think it is. Giving a diagnosis of major depression to a 50 year-old man with a strenuous, unrewarding job might sound like the promise of a disability check. Giving a diagnosis of bipolar disorder to a 15 year-old girl might just sound like a death sentence–especially if the prescribed medication doesn’t relieve her misery. Enough of these instances, and you’ve explained a lot of the above findings. 

So, what has been the response of psychiatry at large to these alarming statistics? After the release of the CDC Suicide Study in June 2018, the President of the APA, Dr. Altha Stewart, tersely announced: “People should know that suicide is preventable. Anyone contemplating suicide should know that help is available, and that there is no shame in seeking healthcare.”  In an interview for Psychiatric News, the past President of the APA, Dr. Maria Oquendo, called for measures to secure handguns to reduce their availability for those at risk, adding that providers should be “vigilant” in assessing suicide risk, and “proactive” in preventing recurrent psychiatric episodes in known patients. 

Frankly, my perception is that psychiatry has always been vigilant and proactive regarding suicide risk.

Ironically, Dr. Oquendo was at the time engaged in research using PET scans and MRIs to map brain abnormalities in mood disorders and suicidal behavior, to “examine the underlying biology of suicidal behavior.” Did she happen to notice that that there was an ongoing epidemic of brain abnormalities?

In the nearly four years since the CDC Study was released, psychiatry has yet to address this epidemiological disaster, much less acknowledge any possible contribution to it. In my social media activities on Twitter, I’ve engaged in lively discourse about the Study with some high profile advocates of biological psychiatry–-who glibly attributed the increase in suicide to “psychosocial factors”, never noticing that this alibi undermines the logic of their own treatment model. Haven't they reviewed Dr. Oquendo's research?

So much for the wisdom of psychiatry at large.

Our pathetic non-response to this Study speaks volumes about the ethical cowardice of our profession. Psychiatry at large is obviously trying very hard to preserve its pride as a profession, and avoid the humiliation of admitting that we may have been heading down the wrong track for decades. The trouble with pride is that it is antithetical to wisdom–which, as we all should know by now, begins with humility. As does science. And as does the Hippocratic Oath–which mandates that above all, we should DO NO HARM. The health of our patients should be placed above our own reputation, above our intellectual comfort, and above our financial wellbeing.

Psychiatry has abandoned its designated mission of treating the psyche–defined as the human mind, soul, or spirit–and now seems to deny its existence. This study calls for us to quit banking on these medications, and to instead acknowledge the fact that pain is a natural consequence of life–and that much of it is instructive for personal growth. Falling back on a cheat sheet of diagnoses that are in fact formulated with the generous assistance of pharmaceutical interests is an inadequate substitute for an actual understanding of what a person is going through, and why they are going through it. In such circumstances medications can at best provide relief–but at the risk of promoting dependence, undermining patient self-confidence, and enabling the avoidance of more definitive solutions.

The clearest example of this is the prescription of antidepressants for patients who are withdrawing from alcohol. Most of the time this happens when the patient is hospitalized for detoxification, which is often driven by the painful circumstances of their chemical dependence–such as legal problems, the alienation of loved ones, or financial ruin. Conventional wisdom holds that motivation for sobriety occurs when the addict hits “rock bottom”--a threshold of consequent misery that is harsh enough to motivate the wholesale changes in life that sobriety demands. In such cases psychic pain is not biological, but reality-based–and not only instructive, but motivational in prodding the patient toward sobriety. Do we want antidepressants to soften the blow in such times–so that they feel less regret about their OUIs and/or impending divorce? Isn’t depression in such cases therapeutic, in the larger view of care?

There’s a budding movement in psychology nowadays built around the idea of resilience–examining the personal qualities that enable some people to be set back by adversities of life, and then come back strong–and how this quality can be cultivated. And there's already another established template for the incorporation of wisdom in modern practice–dialectic behavioral therapy, or DBT, which explicitly pursues the therapeutic goal of establishing Wise Mind. Such approaches confirm that the cure for some psychiatric disorders may already be within us–by accepting the world as it is, and pursuing change within ourselves.  

I think psychiatry has a lot to learn, but simply doesn’t want to learn it.

Why wouldn’t we want to learn it? Why hasn’t the APA addressed the haunting questions raised by the CDC Suicide Study? I think we all know the answer: Because it would be bad for business. 

Over the thirty-four years since Prozac was introduced, countless billions of dollars have been made by the pharmaceutical industry selling products–to people who’ve come to rely upon these medications to maintain their peace of mind. Meanwhile, billions of dollars have been given to the institutions of academic psychiatry to provide research supporting the approval and marketing of their products–the same institutions that train the professionals who will prescribe them.

Psychiatric providers might now see themselves as wedded to medication-oriented practice. But in fact, most prescriptions for psychiatric medications are written by primary care providers, not psychiatric providers. With a deeper understanding of life challenges, and an eclectic array of interventions, a wisdom-oriented psychiatric practice could enable our profession to affirm our expertise, and properly address the dualistic nature of psychiatric disorders. A multidisciplinary group operating in tandem might be the most efficient way to provide such care. 

Such a solution can be dismissed today as a pipe dream. But the statistics I’ve cited make it clear that our current system is first and foremost a business that is based on selling a pipe dream–the idea that medications alone are enough to make our patients happy, and keep our patients alive. I’m not here to sell a solution–that’s well above my paygrade. But I think the failings of our profession are crystal clear–we aren’t saving lives, and we aren’t promoting health. The first step to any solution is to acknowledge the problem. The APA won’t do so, and our academic centers are dragging their heels. So I’m taking it to the street–which nowadays is known as the internet. 

The more immediate solution for all of us is to reconsider this biological framework that we apply to our patients–to contemplate the depth of real-life problems that our patients face, and to reconsider whether their feelings are actually pathological. For example, suppose a patient is depressed because their mother recently died, and makes it clear that they want those feelings to stop. You might want to reframe those feelings, noting that grief is in fact an acknowledgement of the love they have for their mother–and wouldn’t it be awful if we didn’t feel anything? You might share your own experience of losing a loved one. As we all know, misery loves company. It’s a balancing act–being selectively unguarded, even matter-of-fact, yet maintaining the boundaries that are necessary and appropriate. Some patients, however, will inevitably reject your efforts–because the sick role has become their hiding place.  

If you pursue this framework further, you might discover that there are other ways that you can provide assistance to patients. You can listen to the family problems that are contributing to the clinical picture, and cautiously offer advice on how to reframe or resolve those issues–if you have some personal experience to draw upon, or some good ideas to consider. Even failed efforts can be gainful, if the patient appreciates your concern and understanding, and in the end feels more validated and less alone. Anything that might provide direction to a person who feels lost. The key, of course, is to make sure that you are attending to their emotional agenda–and not your own.

My hope is that psychiatry will eventually embrace our ignorance, rediscover wisdom, and honor the mystery that is our amazing brain-mind. A large dose of humility would be good for us, and even better for our patients. If you step outside of our Big Pharma-funded universe, even a casual review of the available literature confirms that wisdom has a long history of demonstrating its efficacy in alleviating anxiety, depression, and mood instability. 

I will conclude with the most complete distillation of humanity’s dilemma that I’ve found–a quote from Socrates that seems to me particularly applicable to psychiatric practice:  

“If you don't get what you want, you suffer; if you get what you don't want, you suffer; even when you get exactly what you want, you still suffer because you can't hold on to it forever.  Your mind is your predicament. It wants to be free of change. Free of pain, free of the obligations of life and death. But change is law, and no amount of pretending will alter that reality.”

Thank you for your time, and your attention. 

REFERENCES

¹Moore, T. J., Mattison, D. R. (2017), Adult utilization of psychiatric drugs and differences by sex, age, and race, JAMA Intern Med. 2017;177(2):274-275. doi:10.1001/jamainternmed.2016.7507

²Brody, D. J., Gu, Q. (2020), Antidepressant Use Among Adults: United States, 2015-2018, NCHS Data Brief No. 377, September 2020

³Hedegaard, H., Curtin, S., Warner, M. (2020), Increase in Suicide Mortality in the United States, 1999–2018, NCHS Data Brief No. 362, April 2020 

⁴Whitaker, R. (2010), Anatomy of an Epidemic, pg. 7-8